Behavioral Health Utilization Specialist

Bcbsla; Louisiana (MO); Hybrid; USD 70,000 - 90,000; Full time

Job summary

Blue Cross and Blue Shield of Louisiana is seeking a Behavioral Health Utilization Reviewer to conduct clinical reviews ensuring medical necessity and appropriateness of care for behavioral health services. You will apply InterQual and medical policy criteria and coordinate with the Behavioral Health Medical Director on complex cases and non-qualifying requests.

You will communicate determinations to providers and members, document decisions, and support the appeals process while maintaining

Qualifications

• Bachelor's degree in nursing, healthcare, or related field.
• Master's degree in social work, counseling, or behavioral health.
• At least 3 years of clinical or patient care experience in behavioral health.
• Licensure: LPC, PLPC, LCSW, LMFT, LMSW, LPN, or RN.

Responsibilities

• Review pre-authorization requests, concurrent reviews, and retrospective claims for behavioral health services.
• Apply InterQual and medical policy criteria to document medical necessity.
• Refer non-qualifying cases to the Psychiatric Medical Director for secondary review.
• Support the appeals process and communicate determinations to providers and members.

Skills

Clinical assessment

Communication

Teamwork

Independent work

Education

Bachelor's degree in nursing or healthcare

Master's degree in social work or counseling

Tools

Electronic health records

Job description

Blue Cross and Blue Shield of Louisiana is seeking a Behavioral Health Utilization Reviewer to conduct clinical reviews ensuring medical necessity and appropriateness of care for behavioral health services. You will apply InterQual and medical policy criteria and coordinate with the Behavioral Health Medical Director on complex cases and non-qualifying requests.

You will communicate determinations to providers and members, document decisions, and support the appeals process while maintaining